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Washington Apple Health (Medicaid)
Diabetes Education
Program Billing
Guide
October 1, 2020
CPT® codes and descriptions only are copyright 2019 American Medical Association.
2 | HCA DIABETES EDUCATION BILLING GUIDE
Disclaimer Every effort has been made to ensure this guide’s accuracy. If an actual or
apparent conflict between this document and a Health Care Authority rule arises,
the rule applies.
Billing guides are updated on a regular basis. Due to the nature of content
change on the internet, we do not fix broken links in past guides. If you find a
broken link, please check the most recent version of the guide. If this is the most
recent guide, please notify us at [email protected].
About this guide* This publication takes effect October 1, 2020, and supersedes earlier billing
guides to this program. Unless otherwise specified, the program in this guide is
governed by the rules found in WAC 182-550-6400.
The Health Care Authority is committed to providing equal access to our services.
If you need an accommodation or require documents in another format, please
call 1-800-562-3022. People who have hearing or speech disabilities, please call
711 for relay services.
Washington Apple Health means the public health insurance
programs for eligible Washington residents. Washington Apple
Health is the name used in Washington State for Medicaid, the
children’s health insurance program (CHIP), and state-only
funded health care programs. Washington Apple Health is
administered by the Washington State Health Care Authority.
Refer also to HCA’s ProviderOne billing and resource guide for valuable
information to help you conduct business with the Health Care Authority.
How can I get HCA Apple Health provider documents? To access provider alerts, go to HCA’s provider alerts webpage.
To access provider documents, go to HCA’s provider billing guides and fee
schedules webpage.
Where can I download HCA forms? To download an HCA form, see HCA’s Forms & Publications webpage. Type only
the form number into the Search box (Example: 13-835).
* This publication is a billing instruction.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
3 | HCA DIABETES EDUCATION BILLING GUIDE
Copyright disclosure Current Procedural Terminology (CPT) copyright 2019 American Medical
Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Fee schedules, relative value units, conversion factors and/or related components
are not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
What has changed?
Subject Change Reason for Change
Entire Guide Revised format of entire
guide.
To comply with
accessibility standards.
Apple Health
Changes for
January 1, 2020
Removed Apple Health
Changes section.
This section is
unnecessary, as it is
outdated. All regions are
now fully integrated
managed care.
Integrated
managed care
regions
Removed listing of regions
and their integration
dates.
This section is
unnecessary, as it is
outdated. All regions are
now fully integrated
managed care.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
4 | HCA DIABETES EDUCATION BILLING GUIDE
Table of Contents Resources Available ............................................................................................................................ 5
Definitions ............................................................................................................................................... 6
About the Program ............................................................................................................................. 7
What is the purpose of the Diabetes Education Program? ........................................ 7
What providers and settings are eligible for this program? ...................................... 7
Client Eligibility ..................................................................................................................................... 8
How do I verify a client’s eligibility? ...................................................................................... 8
Verifying eligibility is a two-step process: ..................................................................... 8
Are clients enrolled in an HCA-contracted managed care organization (MCO)
eligible? ................................................................................................................................................ 9
Managed care enrollment ...................................................................................................... 9
Clients who are not enrolled in an HCA-contracted managed care plan for
physical health services ........................................................................................................ 10
Integrated managed care .................................................................................................... 11
Integrated Apple Health Foster Care (AHFC) ............................................................ 11
Fee-for-service Apple Health Foster Care ................................................................... 12
Coverage ............................................................................................................................................... 13
What is covered? .......................................................................................................................... 13
What is not covered? .................................................................................................................. 13
How do I receive payment? ..................................................................................................... 13
How can I request a limitation extension (LE)? ............................................................. 14
Coverage Table .................................................................................................................................. 15
Billing ...................................................................................................................................................... 16
What are the general billing requirements? ................................................................... 16
How do I bill claims electronically? ..................................................................................... 17
CPT® codes and descriptions only are copyright 2019 American Medical Association.
5 | HCA DIABETES EDUCATION BILLING GUIDE
Resources Available
Topic Contact Information
Information on becoming a
provider or submitting a
change of address or
ownership
See HCA’s ProviderOne Resources
webpage
Information about payments,
denials, claims processing, or
HCA-contracted managed
care organizations
See HCA’s ProviderOne Resources
webpage
Electronic billing See HCA’s ProviderOne Resources
webpage
Finding HCA documents (e.g.,
billing instructions, # memos,
fee schedules)
See HCA’s ProviderOne Resources
webpage
Private insurance or third-
party liability, other than
HCA-contracted managed
care
See HCA’s ProviderOne Resources
webpage
Information on becoming a
diabetes education provider
and obtaining an application
Department of Health
Heart Disease, Stroke, and Diabetes
Prevention Unit
PO Box 47855
Olympia, WA 98504
360- 236-3750
Download and complete the
reimbursement application from the
Department of Health’s Diabetes
Prevention and Management webpage
CPT® codes and descriptions only are copyright 2019 American Medical Association.
6 | HCA DIABETES EDUCATION BILLING GUIDE
Definitions This list defines terms and abbreviations, including acronyms, used in this billing
guide. Refer to chapter 182-500 WAC for a complete list of definitions for
Washington Apple Health.
Authorization – Washington State Health Care Authority’s (HCA’s) official
approval for action taken for, or on behalf of, an eligible Washington Apple
Health client. This approval is only valid if the client is eligible on the date of
service.
Fee-for-service – The general payment method the Health Care Authority uses
to reimburse providers for covered medical services provided to medical
assistance clients when those services are not covered under Health Care
Authority-contracted managed care plans or the Children’s Health Insurance
Program (CHIP).
FIMC “Fully Integrated Managed Care” – A term used to refer to those
designated regions where all Apple Health physical behavioral health benefits are
administered by managed care organization.
Health Care Common Procedure Coding System (HCPCS) – A standardized
coding system used primarily to identify products, supplies, and services not
included in the Current Procedural Terminology (CPT) codes. This includes
ambulance services, durable medical equipment, prosthetics, orthotics, and
supplies when used outside a physician's office.
Maximum allowable fee – The maximum dollar amount that the Health Care
Authority reimburses a provider for specific services, supplies, and equipment.
Usual and customary fee – The rate that may be billed to the Health Care
Authority for certain services, supplies, or equipment. This rate may not exceed
either of the following:
The usual and customary charge billed to the general public for the same
services
If the general public is not served, the rate normally offered to other
contractors for the same services
CPT® codes and descriptions only are copyright 2019 American Medical Association.
7 | HCA DIABETES EDUCATION BILLING GUIDE
About the Program
What is the purpose of the Diabetes Education
Program? The purpose of the Diabetes Education Program is to provide medically necessary
diabetes education to eligible clients. For additional information or more details,
contact [email protected] or call 360-236-3750.
What providers and settings are eligible for this
program? Physicians, advanced registered nurse practitioners, physician assistants,
registered nurses, registered dietitians, pharmacists, clinics, hospitals, and
federally qualified health centers (FQHCs) can apply to the Washington State
Department of Health (DOH) to become an approved diabetes education
provider under this program. Other health professionals who are certified
diabetes educators (CDEs) can also apply.
For more information on becoming a diabetes education provider, contact:
Department of Health
Heart Disease, Stroke, and Diabetes Prevention Unit
PO Box 47855
Olympia, WA 98504
360-236-3750
The reimbursement application can be downloaded and completed from the
Department of Health’s Diabetes Prevention and Management webpage.
Once DOH gives its approval, your National Provider Identifier (NPI) will
acknowledge you as an approved diabetes education provider. When billing the
Health Care Authority (HCA) for diabetes education services, use your NPI.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
8 | HCA DIABETES EDUCATION BILLING GUIDE
Client Eligibility Most Apple Health clients are enrolled in an HCA-contracted managed care
organization (MCO). This means that Apple Health pays a monthly premium to an
MCO for providing preventative, primary, specialty, and other health services to
Apple Health clients. Clients in managed care must see only providers who are in
their MCO’s provider network, unless prior authorized or to treat urgent or
emergent care. See HCA’s Apple Health managed care page for further details.
It is important to always check a client’s eligibility prior to
providing any services because it affects who will pay for the
services.
How do I verify a client’s eligibility? Check the client’s services card or follow the two-step process below to verify
that a client has Apple Health coverage for the date of service and that the
client’s benefit package covers the applicable service. This helps prevent
delivering a service HCA will not pay for.
Verifying eligibility is a two-step process:
Step 1. Verify the patient’s eligibility for Apple Health. For detailed
instructions on verifying a patient’s eligibility for Apple Health,
see the Client Eligibility, Benefit Packages, and Coverage Limits
section in HCA’s ProviderOne Billing and Resource Guide.
If the patient is eligible for Apple Health, proceed to Step 2. If
the patient is not eligible, see the note box below.
Step 2. Verify service coverage under the Apple Health client’s
benefit package. To determine if the requested service is a
covered benefit under the Apple Health client’s benefit package,
see HCA’s Program Benefit Packages and Scope of Services
webpage.
Note: Patients who are not Apple Health clients may submit an application for
health care coverage in one of the following ways:
1. By visiting the Washington Healthplanfinder’s website.
2. By calling the Customer Support Center toll-free at: 855-WAFINDER
(855-923-4633) or 855-627-9604 (TTY)
3. By mailing the application to: Washington Healthplanfinder, PO Box 946,
Olympia, WA 98507
In-person application assistance is also available. To get information about in-
person application assistance available in their area, people may visit the
Washington Healthplanfinder’s website or call the Customer Support Center.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
9 | HCA DIABETES EDUCATION BILLING GUIDE
Clients who want to participate in the Diabetes Education Program must be
referred by a licensed primary health care provider.
Are clients enrolled in an HCA-contracted managed
care organization (MCO) eligible? Yes. Most Medicaid-eligible clients are enrolled in one of HCA’s contracted
managed care organizations (MCOs). For these clients, managed care enrollment
will be displayed on the client benefit inquiry screen in ProviderOne.
All medical services covered under an HCA-contracted MCO must be obtained by
the client through designated facilities or providers. The MCO is responsible for:
Payment of covered services
Payment of services referred by a provider participating with the plan to an
outside provider
Note: A client’s enrollment can change monthly. Providers who
are not contracted with the MCO must receive approval from
both the MCO and the client’s primary care provider (PCP) prior
to serving a managed care client.
Send claims to the client’s MCO for payment. Call the client’s MCO to discuss
payment prior to providing the service. Providers may bill clients only in very
limited situations as described in WAC 182-502-0160.
Managed care enrollment Apple Health (Medicaid) places clients into an HCA-contracted MCO the same
month they are determined eligible for managed care as a new or renewing
client. This eliminates a person being placed temporarily in FFS while they are
waiting to be enrolled in an MCO or reconnected with a prior MCO. This
enrollment policy also applies to clients in FFS who have a change in the program
they are eligible for. However, some clients may still start their first month of
eligibility in the FFS program because their qualification for MC enrollment is not
established until the month following their Medicaid eligibility determination.
New clients are those initially applying for benefits or those with changes in their
existing eligibility program that consequently make them eligible for Apple
Health managed care.
Checking eligibility
Providers must check eligibility and know when a client is enrolled and with
which MCO. For help with enrolling, clients can refer to the Washington
Healthplanfinder’s Get Help Enrolling page.
MCOs have retroactive authorization and notification policies in place. The
provider must know the MCO’s requirements and be compliant with the
MCO’s policies.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
10 | HCA DIABETES EDUCATION BILLING GUIDE
Clients have a variety of options to change their plan:
Available to clients with a Washington Healthplanfinder account:
Go to Washington HealthPlanFinder website .
Available to all Apple Health clients:
o Visit the ProviderOne Client Portal website:
o Call Apple Health Customer Service at 1-800-562-3022. The automated
system is available 24/7.
o Request a change online at ProviderOne Contact Us (this will generate
an email to Apple Health Customer Service). Select the topic
“Enroll/Change Health Plans.”
For online information, direct clients to HCA’s Apple Health Managed Care
webpage.
Clients who are not enrolled in an HCA-contracted
managed care plan for physical health services Some Medicaid clients do not meet the qualifications for managed care
enrollment. These clients are eligible for services under the FFS Medicaid
program. In this situation, each Integrated Managed Care (IMC) plan will have
Behavioral Health Services Only (BHSO) plans available for Apple Health clients
who are not in managed care. The BHSO covers only behavioral health treatment
for those clients. Clients who are not enrolled in an HCA-contracted managed
care plan are automatically enrolled in a BHSO with the exception of American
Indian/Alaska Native clients. Some examples of populations that may be exempt
from enrolling into a managed care plan are Medicare dual-eligible, American
Indian/Alaska Native, Adoption support and Foster Care alumni.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
11 | HCA DIABETES EDUCATION BILLING GUIDE
Integrated managed care Clients qualified for managed care enrollment and living in integrated managed
care (IMC) regions will receive all physical health services, mental health services,
and substance use disorder treatment through their HCA-contracted managed
care organization (MCO).
American Indian/Alaska Native (AI/AN) clients have two
options for Apple Health coverage:
- Apple Health Managed Care; or
- Apple Health coverage without a managed care plan (also
referred to as fee-for-service [FFS])
If a client does not choose an MCO, they will be automatically
enrolled into Apple Health FFS for all their health care services,
including comprehensive behavioral health services. See the
Health Care Authority’s (HCA) American Indian/Alaska Native
webpage.
For more information about the services available under the FFS
program, see HCA’s Mental Health Services Billing Guide and
the Substance Use Disorder Billing Guide.
For full details on integrated managed care, see HCA’s Apple Health managed
care webpage and scroll down to “Changes to Apple Health managed care.”
Integrated Apple Health Foster Care (AHFC) Children and young adults in the Foster Care, Adoption Support and Alumni
programs who are enrolled in Coordinated Care of Washington’s (CCW) Apple
Health Foster Care program receive both medical and behavioral health services
from CCW.
Clients under this program are:
Under the age of 21 who are in foster care (out of home placement)
Under the age of 21 who are receiving adoption support
Age 18-21 years old in extended foster care
Age 18 to 26 years old who aged out of foster care on or after their 18th
birthday (alumni)
These clients are identified in ProviderOne as “Coordinated Care
Healthy Options Foster Care.”
CPT® codes and descriptions only are copyright 2019 American Medical Association.
12 | HCA DIABETES EDUCATION BILLING GUIDE
The Apple Health Customer Services staff can answer general questions about
this program. For specific questions about Adoption Support, Foster Care or
Alumni clients, contact HCA’s Foster Care Medical Team at 1-800-562-3022, Ext.
15480.
Fee-for-service Apple Health Foster Care Children and young adults in the fee-for-service Apple Health Foster Care,
Adoption Support and Alumni programs receive behavioral health services
through the regional Behavioral Health Services Organization (BHSO). For details,
see HCA’s Mental Health Services Billing Guide , under How do providers identify
the correct payer?
CPT® codes and descriptions only are copyright 2019 American Medical Association.
13 | HCA DIABETES EDUCATION BILLING GUIDE
Coverage
What is covered? The Health Care Authority covers up to six hours of diabetes education and
diabetes management per client, per calendar year.
You must provide a minimum of 30 minutes of diabetes
education/management per billed unit.
You may:
o Bill procedure codes as a single unit, in multiple units, or in combinations
for a maximum of six hours (12 units). You may use any combination of
the codes to meet the individual needs of the client.
o Provide diabetes education in a group or individual setting, or a
combination of both, depending on the client’s needs.
Note: Additional units of diabetes education beyond these
limits may be approved upon request based on medical
necessity. For more information, see How can I request a
limitation extension (LE)?
What is not covered? The Health Care Authority does not cover:
Services provided by an individual instructor or facility that has not been
approved by DOH.
Services performed by providers that have not been approved to bill Medicaid
for diabetes education.
Services that are an expected part of another program provided to the client
(e.g., school-based healthcare services or adult day health services).
How do I receive payment? For diabetes education services provided in a professional (non-hospital)
setting, you must:
Bill either HCPCS code G0108 or G0109 using an electronic professional claim.
Bill using the main clinic NPI in the Billing Provider NPI field along with the
individual practitioner’s NPI in the Rendering (Performing) Provider NPI field
on an electronic professional claim. The Health Care Authority will only pay for
diabetes education that is billed by an approved diabetes education provider.
Provide a minimum of 30 minutes of education/management per session.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
14 | HCA DIABETES EDUCATION BILLING GUIDE
For services provided in a hospital outpatient setting, you must:
Bill using revenue code 0942.
Provide a minimum of 30 minutes of education/management per session.
Note: Services provided in the outpatient clinic must be
submitted on a professional claim to receive payment. Services
provided in the outpatient setting, but not in the clinic, must be
submitted on an institutional claim to receive payment.
Note: The Health Care Authority requires authorized hospital
outpatient diabetes education programs to bill with revenue
code 0942. Use of HCPCS codes G0108 and G0109 will cause a
denial of the claim.
How can I request a limitation extension (LE)? When clients reach their benefit limit of diabetes education, a provider may
request prior authorization for an LE from the Health Care Authority.
The Health Care Authority evaluates requests for prior authorization of covered
diabetes education that exceed limitations in this billing guide on a case-by-case
basis in accordance with WAC 182-501-0169. The provider must justify that the
request is medically necessary (as defined in WAC 182-500-0070) for that client.
Note: Requests for an LE must be appropriate according to the
client’s eligibility or program limitations. Not all eligibility
programs cover all services.
The following documentation is required for all LE requests:
A completed General Information for Authorization form (HCA 13-835, see
Where can I download HCA forms?)
o This request form MUST be the first page when you submit your request.
A completed Fax/Written Request Basic Information form (HCA 13-756, see
Where can I download HCA forms?), all of the documentation listed on this
form, and any other medical justification
Fax LE requests to: (866) 668-1214
CPT® codes and descriptions only are copyright 2019 American Medical Association.
15 | HCA DIABETES EDUCATION BILLING GUIDE
Coverage Table
Procedure/Revenue Codes Short Description Maximum Allowable Fees
Procedure code G0108* Diab manage trn per indiv, per session
One unit = 30 minutes
Rates Development Fee
Schedules
Procedure code G0109* Diab manage trn ind/group
One unit = 30 minutes
Rates Development Fee
Schedules
Revenue code 0942* Diab manage trn per indiv per session
or diab manage trn ind/group
Rates Development Fee
Schedules
*Procedure codes G0108 and G0109 are for professional (non-hospital) billing,
and revenue code 0942 is for outpatient hospital billing.
CPT® codes and descriptions only are copyright 2019 American Medical Association.
16 | HCA DIABETES EDUCATION BILLING GUIDE
Billing
All claims must be submitted electronically to the Health Care
Authority, except under limited circumstances.
For more information about this policy change, see Paperless
Billing at HCA.
For providers approved to bill paper claims, see the Health Care
Authority’s Paper Claim Billing Resource.
What are the general billing requirements? Providers must follow the Health Care Authority’s ProviderOne Billing and
Resource Guide. These billing requirements include the following:
What time limits exist for submitting and resubmitting claims and adjustments
When providers may bill a client
How to bill for services provided to primary care case management (PCCM)
clients
How to bill for clients eligible for both Medicare and Medicaid
How to handle third-party liability claims
What standards to use for record keeping
CPT® codes and descriptions only are copyright 2019 American Medical Association.
17 | HCA DIABETES EDUCATION BILLING GUIDE
How do I bill claims electronically? Instructions on how to bill Direct Data Entry (DDE) claims can be found on the
Health Care Authority’s Billers and Providers webpage, under Webinars.
For information about billing Health Insurance Portability and Accountability Act
(HIPAA) Electronic Data Interchange (EDI) claims, see the ProviderOne 5010
companion guides on the HIPAA Electronic Data Interchange (EDI) webpage.
The following claim instructions relate to the Diabetes Education Program:
Name Entry
Place of Service Enter the appropriate two-digit code
as follows:
Use Code Number 11 for Office
Use Code Number 22 for Outpatient
Hospital
Billing Provider Enter the provider’s Provider NPI and
Taxonomy Code
Rendering (Performing) Provider Enter the individual practitioner’s
Provider NPI and Taxonomy Code
